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Acupuncture, including sham acupuncture, is more effective than conventional therapy for back pain, reported four newspapers (25th September 2007). The newspapers were generally accurate in their reports of a well conducted randomised controlled trial.

On the 25 September 2007, four newspapers (1-6) reported that acupuncture, including sham acupuncture, is more effective in reducing chronic lower back pain and improving function than conventional therapy.
The newspaper reports were based on the findings of a randomised controlled trial involving 1162 adults (7). Participants were assigned to one of three treatment groups: acupuncture, sham acupuncture or conventional therapy (combination of medication, physiotherapy and exercise). The trial found that 47% receiving genuine acupuncture and 44% receiving sham acupuncture demonstrated a significant improvement in back pain or function compared to 27% receiving conventional therapy. No statistically significant difference between the two acupuncture groups was found.
The newspaper reports were generally accurate in their descriptions of key details of the randomised controlled trial. One newspaper (2) reported that acupuncture was 74% more likely to lead to a sustained reduction in pain or improved ability to function normally than conventional treatment; it is unclear where this figure comes from. This was a generally well conducted trial and the findings are likely to be reliable.

Evaluation of the evidence base for acupuncture for chronic lower back pain.

Where does the evidence come from?

The trial was conducted by Dr Michael Haake at the Orthopedic Department, University of Regensburg and colleagues across Germany. The study was supported by a number of German public health insurance companies.

What were the authors' objectives?

The authors' objectives were to compare the efficacy of acupuncture, sham acupuncture and conventional therapy for the treatment of chronic low back pain.

What was the nature of the evidence?

This was a randomised controlled trial conducted across 340 outpatient practices in Germany. Patients aged 18 years or more with chronic lower back pain for at least 6 months, a mean pain intensity score of grade 1 or higher (Von Korff Chronic Pain Grade Score) and a Hanover Functional Ability score of less than 70% were eligible for inclusion in the trial. Patients who had not been therapy free for at least seven days, who had previously received needle acupuncture for the treatment of low back pain, who had previous spinal surgery, previous spinal fractures, infectious, or tumorous spondylopathy, or chronic pain caused by other diseases were excluded.

What interventions were examined in the research?

Patients were randomly assigned to one of three treatment groups: verum acupuncture (14-20 needles inserted to a depth of 5-40mm at various acupuncture points) (n=387), sham acupuncture (superficial needling at non-acupuncture points) (n=387) or conventional therapy according to German guidelines (combination of medication, physiotherapy and exercise) (n=387). All intervention groups underwent ten half-hour sessions, typically two per-week. Five additional sessions were received if after the tenth session patients experienced a 10% to 50% reduction in pain intensity. All those administering acupuncture had at least 140 hours of acupuncture training. Patients were blind to the type of acupuncture they were receiving.

Patients were evaluated at 6 weeks, 3 months and at 6 months. The primary outcome of interest was response after 6 months, defined as a 33% improvement or better on three pain-related items on the Von Korff Chronic Pain Grade Scale questionnaire or a 12% improvement or better on the back-specific Hanover Functional Ability Questionnaire. Outcome measures were assessed by telephone interviews. Interviewers were blind to the method of acupuncture received.

What were the findings?

At 6 months, 47.6% of patients receiving verum acupuncture and 44.2% receiving sham acupuncture demonstrated a significant improvement in back pain or function compared to 27.4% receiving conventional therapy. No statistically significant difference between the two acupuncture groups was found.

Forty serious adverse events were reported, 12 each in the acupuncture groups and 16 in the conventional therapy group; all were thought to be unrelated to the intervention. 476 clinically relevant adverse events were also recorded for 257 patients; no statistically significant between group difference was shown.

What were the authors' conclusions?

The authors concluded that treatment with acupuncture improved low back pain for at least six months, and that both verum acupuncture and sham acupuncture were almost twice as effective as conventional therapy.

How reliable are the conclusions?

This was a multicenter, randomised controlled trial that employed an appropriate method of randomisation and analysed participants according to the groups to which they were randomised. It was also reported that patients and interviewers were blind to the type of acupuncture they received, which reduces the possibility of bias. The treatment groups were broadly comparable at baseline. Outcome measures were largely self-reported, which may have introduced some bias. The authors highlight possible limitations in the restriction of acupuncture to needling only and the inability to blind acupuncturists to the form of acupuncture. This was a generally well conducted trial and the findings are likely to be reliable.

Systematic reviews

Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.

There was one related systematic review identified on the Cochrane Database of Systematic Reviews (CDSR) (8) and six on the Database of Abstracts of Reviews of Effects (DARE) (9-14).

References and resources

1. Acupuncture 'is better at easing pain'. Daily Telegraph, 25 September 2007, p1.

2. Acupuncture 'most effective therapy for back pain'. Daily Telegraph, 25 September 2007, p12.

3. Acupuncture 'works'. The Times, 25 September 2007, p1.

4. Sticking needles in a bad back 'eases pain better than drugs'. The Times, 25 September 2007, p4.

5. Acupuncture is best way to treat back pain, study finds. The Independent, 25 September 2007, p11.

6. A few needles stuck in your back 'could ease pain better than drugs'. Daily Mail, 25 September 2007, p.17.

7. Haake M, Muller HH, Schader-Brittinger C, Basler HD, Schafer H, Maier C, Endres HG, Trampisch HJ, Molsberger A. German acupuncture trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Archives of Internal Medicine 2007;167:1892-98.

8. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.

9. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Annals of Internal Medicine 2005;142(8):651-663. [DARE Abstract]

10. Henderson H. Acupuncture: evidence for its use in chronic low back pain. British Journal of Nursing 2002;11(21):1395-403. [DARE Abstract]

11. Ezzo J, Berman B, Hadhazy V A, Jadad A R, Lao L, Singh B B. Is acupuncture effective for the treatment of chronic pain: a systematic review. Pain 2000;86(3):217-225. [DARE Abstract]

12. Strauss A J. Acupuncture and the treatment of chronic low-back pain: a review of the literature. Chiropractic Journal of Australia 1999;29(3):112-118. [DARE Abstract]

13. van Tulder M W, Cherkin D C, Berman B, Lao L, Koes B W. The effectiveness of acupuncture in the management of acute and chronic low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 1999;24(11):1113-1123. [DARE Abstract]

14. Ernst E, White A R. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Archives of Internal Medicine 1998;158(20):2235-2241. [DARE Abstract]